Tourniquet: Fact v. Fiction
Recently, I was reading a popular wilderness first-aid handbook that is used to trained thousands of Americans each year and one of the sections really bothered me. In its outline of how to control severe bleeding, it indicated that a tourniquet is used “only” as a last resort since it may “cause gangrene” and “may require surgical amputation of the limb.” The handbook also advises that in the event that a tourniquet must be used, that it should be loosened in “five minute” intervals to check if bleeding has stopped and to “allow some blood flow” to the affected limb. Sounds reasonable enough, right? Except that it isn’t accurate.
According to much medical evidence, the reality is that a tourniquet, used by a trained wilderness first-aid provider, may, in fact, be the initial method of bleeding control in severe extremity bleeding.
Much of what the medical community now knows about the use of the tourniquet stems from substantial research conducted by the US military following, sadly, more than ten years of repeated battlefield use in Iraq and Afghanistan. While tourniquets have long been, in a sense, feared, by civilian first-aid providers, the military has shown that not only are tourniquets effective, but they typically have minimal complications. More to the point: there have been no reported amputations from military tourniquet applications.
Understanding the tourniquet and its use is important for two reasons. First, extremity bleeding is one one of the most preventable causes of death. Second, while the backcountry setting is certainly not the same as that of an active firefight, there are many similarities that make the tourniquet a potentially lifesaving tool. A short list includes hunting accidents, logging injuries, and rock climbing falls.
There are many types of tourniquets from which to choose, but some are better than others. While the cravat and stick method is fine as a last resort, it is not ideal. Instead, there are two types that have undergone extensive battlefield testing and are available to civilians and easily affordable ($25-40). The Combat Action Tourniquet (CAT) and the SOF-Tactical Tourniquet are designed to be applied in seconds, even with one hand. They utilize a self-adhering band with hook and loop closures, and incorporate a windlass system to ensure a tight fit. They are both small and lightweight, fitting easily into a backpack first-aid kit.
There are guidelines for tourniquet use. The tourniquet is indicated for life-threatening extremity bleeding only. That is, it should not be used where direct pressure can easily stop the bleeding. Also a tourniquet should be applied on the skin surface (excluding an extremity joint, like an elbow), with the primary pressure on an artery. While many first aid manuals indicate that a tourniquet be placed 2-3 inches above the wound, most Emergency Department physicians strongly suggest simply setting the tourniquet in the upper portion of the extremity, no matter the distance from wound since the maximum of pressure can be placed on the artery. If necessary, though, the CAT and SOF-Tac are designed to fit directly over clothing, thus saving precious time; whereupon excess clothing can be removed, and the tourniquet better positioned if necessary, during a later detailed physical examination.
One common mistake when applying a tourniquet is doing so too loosely. A properly applied tourniquet should eliminate the distal pulse in the affected limb. Understand, too, that when a tourniquet is properly applied, it will hurt!
In a wilderness setting, the protocol is that, once applied, the tourniquet should be left in place until definitive medical care is reached. Several military studies have indicated an increased death rate if tourniquets are removed, even temporarily. While there is the increased possibility of later amputation of the affected limb (with severe emotional consequences), not too mention the extreme pain while it is in place, there is the greater risk of death from the additional blood loss that ongoing, repeated removals of the tourniquet would cause. However, the same military research has found that tourniquets have been left in place up to 6 hours with no lasting effects.
Please keep in mind that I am not now attempting to provide you a definitive lesson in tourniquet use (there is a lot more information available). However, for those of you who are wilderness first-aid trained, I would stress that it is important to at least be up to date in your knowledge and training, and to be aware of available tools. By contrast, for those of you who have never taken such a course, but who spend time in the outdoors (especially leading groups), I would strongly suggest that you register for one. After all, a tourniquet and the proper training may prove to be an invaluable investment.
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Disclaimer: This blog does not constitute medical advice, nor should it be interpreted as a substitute for appropriate medical training.
